Peertechz Journal of Pediatric Therapy

Carlos Alberto Snchez Salguero*

Case Report

Head of Pediatric Allergy and Pneumology

Department. Professor of Pediatric. Medicine School
of Cdiz. University Hospital Puerto Real (Cdiz).
Spain

Oral Desensitization in Nursling with

Cows Milk Allergy

Dates: Received: 29 October, 2015; Accepted: 20

November, 2015; Published: 23 November, 2015
*Corresponding author: Carlos Alberto Snchez
Salguero, MD, PhD. Head of Pediatric Allergy and
Pneumology Department. Professor of Pediatric.
Medicine School of Cdiz. University Hospital Puerto
Real (Cdiz). Spain. Email:
www.peertechz.com
Keywords: Allergy; Cows milk proteins;
Desensitization; Prick-test; Tolerance; SOTI;
Anaphylaxis; Infant

Abstract
Food allergy is a major public health problem affecting nearly 10 % of children in most industrialized
countries. Unfortunately, there are no effective therapies for food allergy, relegating patients to simply
avoid the offending foods and treating the reactions which occur on accidental exposure. Recently
however, studies suggest that food immunotherapy may provide a promising new approach to food
allergy, particularly using the oral form of immunotherapy (OIT). Enthusiasm for this approach though
must be tempered because of the significant allergic reactions that often occur with OIT that tends to
limit its use to patients with less severe disease. Actually this technique of desensitization is applied in
child with ages over 5 years old, because many investigators think that this is the frontier from which
the allergy is persistent all the life, and before this age the possibilities of natural tolerance to milk is
very much probability. In contrast to this, are few investigational groups dedicated to try to desensitize
children under 1 years old, and less in the first 6 months of the life, due to the high possibilities of
secondary reactions, especially anaphylaxis.

Clinical Case
Nursling with 6 months old who is send to the Pediatric Allergy
Unit from his Health Center for having presented, with 5,5 months
old an urticarial reaction with great wheals and angioedema areas in
the face, after the eating artificial feeding.
In the first visit at our Unit come both parents and they said that
they were witnesses when the reaction happened. They referred that
until this moment, the nursling was eating exclusive breastfeeding
and they had introduced, only, natural orange juice diluted with
water, in small amount two or three times in a day.
In the moment of the birth, they decided the breastfeeding
although the first days of the infant life he received infant cows
milk in Maternity Unit of the hospital while the mother was in the
Intensive Care Unit due to complications that arose at the end of the
gestation.

Familiar history
The parents said that they had some family members with
different allergies (rhinitis, asthma, etc.). The father presented an
allergy asthma and rhinoconjunctivitis process with sensitization to
Dermatophagoides pteronissinus and Dermatophagoides farinae,
besides grass and olive pollen. The mother presented an allergy
rhinitis with sensitization at the same mites, and she was diagnosed
of Oral Allergy Syndrome when she ate shrimps, and this process had
worsened during the pregnancy due to Tropomiosins sensitization.
Paternal and maternal grandparents also referred symptoms of
respiratory illnesses due to allergy process.
They have other child of 4 years old without allergy problems.
Other illnesses in family history were Insulin Dependent Diabetes.

History of Present Illnes

The pregnancy of the mother was physiological and she referred

vomiting episodes in the three first months of the pregnancy, without

medication need for the control. The mother had healthy life with
sport activity and without tobacco cigarette, alcohol and other drugs.
The newborn presented APGAR 9-10-10 (1st-5th-10th minutes
of life), with amniotic liquid with blood, and without need
cardiopulmonary resuscitation. After the birth he was transport
in incubator to the Neonatology Unit where, and when the nurses
were sure that the mother cannot gave maternal lactation, the infant
received artificial milk begining with 30 ml amount each three hours
and 40 ml the next day. In total he received 12 intakes of milk with
a total quantity of 400 ml of milk which would correspond to 540
grams of milk proteins.
During within the first intakes the parent didnt refer any presence
of complications or dermatological problems.
After the recovery of the mother, the infant began exclusively
breast feeding. The maternal feeding had been variety and healthy
without restriction of milk foods.
They did not observe atopic dermatitis, although the mother said
that in some moments she used in the newborn skin body cleansing
wipes that one of the components was milk and she saw that the
areas where she applied these wipes began to be irritated during few
minutes.

Case History
The parent decided to give at the infant artificial feeding. The
first day the feeding bottle was prepared with continuation artificial
feeding, also with cow milk prepared, using 180 milliliters of water
with six scoops of milk without wheals.
The mother observed that with the first sucking movements, the
child began to cry and reject the bottle, which she thought was due to
the bottle nipple, insisting in the take. Five minutes later the mother
saw that her child presented a reaction with facial erythema most

Citation: Snchez Salguero CA (2015) Oral Desensitization in Nursling with Cows Milk Allergy. Peertechz J Pediatr Ther 1(1): 005-008.

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Snchez Salguero (2015)

intensive around the mouth and with a fast evolution in crane caudal
direction and the emergence of hives of different sizes that tended to
meet in the skinfolds. Also the lessions of the face had a purplish color
with white center and the lips began to inflame. In that moment the
mother stopped the bottle feeding and the child was urgently taken
to the Emergency Unit where after explore at the patient, the doctors
decided to inject intramuscular corticosteroid (metilprednisolone).
The child had, at all times, respiratory and cardiac frequencies in
normal values moreover an oxygen level in blood between 98-100%
breathing ambient air, without need oxygen supplementary.
After the finish of this process and with the suspect of Cows Milk
Protein Allergy the doctors of the Emergency Unit banned the feeding
with cow milk, and the indicated a special formula with hydrolyzed
casein formula.
The infant was derivate to the Pediatric Allergy Unit with
preference and he was visit 3 days after. There, after talking with
the mother, the nurse made a Prick test using a drop of whole milk,
alfalactoalbumin, betalactoglobulin and casein. The result of this
diagnostic method, using a commercial kit of Stallergens laboratory
(Lactotest) and after 20 minutes, was consider positive with a
diameters hives of 4x5 millimeters (mm) for whole milk, 3x3 mm
for alfalactoalbumin, 3x4 mm for betalactoglobulin and 6x5 mm for
casein with a positive control (histamine) of 3x3 mm [1].
Due to this test positivity was practice an analysis of blood at the
infant and to determinate the levels of alfalactoalbumin (Bos d4),
betalactoglobulin (Bos d5), casein (Bos d8), serum albumin (Bos d6)
and dlactoferrin (Bos lac) with Phadiatop proceeding. The results was
the next:
- n Bos d4: 13.4 UI/ml
- n Bos d5: 16.8 UI/ml
- n Bos 6: 9.76 UI/ml
- n Bos d8: 25.6 UI/ml
- n Bos lac: 4.31 UI/ml
Although the data got in Phadiatop test together with the patient
clinic status give us the diagnostic of Cows Milk Protein Allergy
[2,23], it was necessary, after the parents sign the legal authorization,
that the patient was subjected with an oral provocation using 1 ml of
commercial milk. 2 hours after the administration of the milk, the
patient presented an urticarial generalized state without breathing,
digestive or cardiac symptoms, so it was no classified as anaphylaxis.
The order was give him 2,5 ml of Dexclorfeniramine (Polaramine)
and the skin lesions disappeared in 10 minutes [3].
The parent were informed about the diagnostic of Cows Milk
Allergy and we offered the possibility of a novel treatment. The parent
had two possibilities: in first place they could eliminated the cows
milk and foods than had this protein changing for a hydrolyzed milk,
as they had been doing until that moment and having at their home
adrenaline autoinyectors for administrate in case of anaphylaxis
[4,18].
The second option was began in that moment the desensitization

process, thereby to get the tolerance to the milk of the infant,

decreasing the risk of anaphylaxis [5].
The parent chose for the desensitization technique so that we
proceeded to give at the infant dilutions of milk and water according
to a protocol established in our Pediatric Allergy Unit. After give
one dosage of 2,5 ml of Dextromethorphan and with precharged
adrenaline for if we can need it, the first day we prepared a dilution
1/100 (1 ml of milk and 100 ml of water) administering 1 ml by the
mouth and checking the infant was free of allergy symptoms. After
this, and each 1 hour, we gave at the infant dosage of 2-4-8 and 16 ml
of the same dilution. The symptoms presented by the baby was mild
facial exanthema that stopped with a new dosage of antihistamine.
During the rest of the day the infant was under clinic vigilance in
Pediatric Unit with cardiac and respiratory monitoring and we could
check absence of allergy symptoms.
The second day, and using the same milk dilution 1/100 we gave
him 16 ml and one hour after 32 ml with presented symptoms. Later
we did a new dilution 1/10 (1 ml of milk and 10 ml of water) giving
him 6-12-24 ml each hour, and the baby was asymptomatic all the
day, with cardiac and respiratory frequency between normal values.
The third day we began with 24 ml of 1/10 dilution and one hour
after 24 ml more, this was a total accumulative dosage of milk of 5 ml
with normal tolerance.
After these three days the infant returned at his home with the
parent and with the order of taken 5 ml of milk, during the mornings
in the first take of the day and the rest of the food using the hydrolyzed
milk avoiding new foods in the baby diet.
After one week the baby and his parent return at the Pediatric
Hospital Day proceeding to administrate10 ml of milk, en twice of 5
ml separated one hour between them. Two hours after the last dosage
he presented mild facial erythema which disappeared after gave him
Dexclorfeniramine.
The baby had been coming at our Hospital each week with
successive increases of 20 ml, 40 ml and nowadays he is in the time
of taking 60 ml of baby milk and having introduced other foods like
vegetables, chicken, turkey, veal and gluten without allergy symptoms
none of them. Actually we have get the total amount of 240 ml of
cow milk and if the baby needs to receive more milk the diet is
complementary with hydrolyzed milk. In the next weeks we are going
to increase this quantity until the total amount of 500 ml of milk in
a day.

Discussion
The cows milk protein is the first antigen which a baby take
contact in his life, either by transmission by the maternal milk due
that these proteins includes in the normal diet of the mothers have the
ability to cross the milk ducts, or due to be the first non-autologous
antigen different at the maternal milk protein that the babies receive
in their lives in great quantities.
Cows Milk Protein Allergy is the name to all those clinical cases
in which is possible to demonstrate an immunological mechanism
[6], and must exist a direct relation between the ingestion of cows

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Snchez Salguero (2015)

milk and the appearance of the symptoms. It is therefore that the

immediately hypersensitivity reactions or mediated by IgE are
which presented a common symptomatology, easily recognized and
ascertainable.
Sometimes the infants are diagnosed of Non Mediated IgE Cows
Milk Protein Allergy. The majority of the patients present principal
digestives symptoms with mild or few cutaneous reactivity, and these
infants are without symptoms when the milk is retire of the diet. In
these patients are more striking the diarrhea with mucus and blood,
intestinal colic, gastroesophagical reflux and insomnia with risk of
malnutrition.
The epidemiological dates show a variability between 2-3% with
an incidence of adverse reactions of 0.5-7.5% during the first year of
life. Studies developed in Spain described that the cows milk allergy is
the third cause of food allergy after egg and fish. The cows milk present
a composition with more than 40 proteins that can act as antigens.
The principals allergens are betalactoglobulin, casein with different
subunits, alfalactoalbumin and seroalbumin; betalactoglobulin is a
protein which do not exist in the maternal milk but is eliminated in
the maternal milk due the diet of the mother (this is the cause that this
protein is the first awareness of the babies) [13].
In most cases the symptomatology appear when the infant start
the artificial feeding after a period of maternal feeding. This is the
reason why the age of beginning the symptoms is related with the age
of beginning the artificial feeding, with a peak incidence between 3-4
months of life, and exceptional after the second year of life.
The reactions can be classified, as time of start, in immediately
(is easy to demonstrate the role of IgE), intermediate and late. The
symptoms are varied, but is possible to resume in cutaneous (erythema
or perioral urticarial), digestive symptoms (diarrhea with mucus and
blood or vomiting) related with the levels of alfalactoalbumin protein,
respiratory symptoms (stridor, cough, nasal or ocular pruritus); and
by last, the most serious cases can present anaphylaxis [12].
The diagnosis besides a complete clinical history in which is
necessary to demonstrate the relation between the ingestions of cows
milk and the appearance of the clinical symptoms, we can use various
techniques to help us in the confirmation of this diagnostic, although
this is not all that we can do [6].
In first place one of the most simples, easier, comfortable and
cheap techniques to do is Prick- Test. This technique consist on
the placement of different extracts of proteins (alfalactoalbumin,
betalactoglobulin, casein) besides whole milk and compare with a
positive (histamine) and negative control (physiological whey) [1].
After is necessary to use a lancet and puncture the skin with the lancet
crossing the drop of liquid that contains the allergen and arrive at
epidermis to allow that the above allergen penetrates and contact
with antigen presenting cells (APG), starting so the hypersensitive
reaction and forming a wheal between 5-20 minutes later. Once
elapsed time one proceeds to measure the size of the different wheals,
starting with positive and negative control (the presence of a positive
control without wheal indicates two situations; first and the most
common is the taking of an antihistamines, or the second options are
the diagnostics of anergia, special situation of the babies in which is

possible the absence of histamine in the skin; while the presence of a

negative control with a wheal indicates the opposite, hyperergia due
to excess of histamine in the skin in such the dermis reacts forming
a wheal as consequence of low traumatism). This technique only
indicates sensitization of the patient at the cows milk protein and
never must be considered allergy [7].
A second technique in the diagnostic is the determination of
specifics antibodies levels using quantification and that nowadays
are commercialized for alfalactoalbumin, betalactoglobulin, casein,
seroalbumin and lactoferrin [8]. The presence of high levels of this
antibodies indicate us, like Prick-Test, sensitization of the patient;
but if we want to certificate the allergy in the patient we need a
correlation with the clinical history , or in case of doubt we need to do
a Controlled Oral Challenges Test Food (COCTF) [9].
The COCTG consists of administering the food that we are
studying as cause of the patient allergy, in small quantities trying to
relate the food ingestion to the presentation of the symptoms of the
allergy. Is a technique not exempt or risks and must be made only
in recognized Pediatric Allergy Units, with training professionals
(doctors, nurses) and with all the means appropriated for avoiding
dangerous situations (high anaphylaxis, respiratory disorders, etc.)
[19,20].
If the COCTG is positive, that is the patient suffers a reactions,
we have two options. Until a few years these patients have forbidden
the ingestion of milk or food with possibilities of containing these
proteins, which cause several problems in the quality of life of the
patients and their families. They might be sure that the food will not
have milk and they might transport autoinyectors of adrenaline to
puncture in case of anaphylaxis. And they had to use hydrolyzed
milk, or if the infant had more than one year old he could drink soy
milk, with the possibility of new allergic reactions at soy protein.
There are many studies published in which the authors
demonstrate the incidence in quality of life and how impact in the
familiar economy, increasing costs [17].
From ten years ago, we have a therapeutic weapon based on the
concept of desensitization. The Specific Oral ImmunoTherapy (SOIT)
also named as Specific Oral Tolerance Induction (SOTI) consists
in administering milk dilutions with concentrations each higher,
starting with dilution with water 1/100 (1 milliliter of milk and 100 ml
of water) and increasing the total quantity of milk protein offered at
the patient, changing the dilution and arriving the moment in which
the patient take whole milk, depending of the tolerance capacity of the
patients, sometimes is possible to arrive at the end of the technique
taking 240 ml of whole milk, or sometimes the infant or child cannot
increasing the dosage due to undesirable side effects [10,11,26,27].
Undoubtedly this is a technique in which we can quantify in
every moment the quantity of milk proteins that we are given at the
patient, different each one and depending the tolerance capacity; so
some patients could tolerate 5 ml/day, others 24 ml/day or 240 ml/
day (exits conversion tables with foods that contains lacteal derivate
such as cheese, yogurts, etc.) [14].
Though the SOTI technique began to develop the patients were

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selection with more than 5 years old, nowadays the Pediatric Allergy
units accept patients under this age, coming near to desensitization
in breastfed babies of 6 months old (as we show in our case). This
technique has a continuous develop, and once the patient reaches
the maximum tolerance dosage is necessary that all the days take the
same dosage for keep the immunological memory of tolerance. Other
investigations groups are trying to demonstrate that if the child stop
drink of milk and after he the patient is submitted at a Controlled
Oral Challenges Test Food, is possible that allergy symptoms dont
show, reaching the total tolerance [15,16,22].

Conclusion
Although OFD may sometimes be successful and may be
considered a valid alternative to an elimination diet, further
randomized controlled trials are needed, in order to clarify some
controversial points, such as the characteristics of the child undergoing
OSIT, and the methods of food preparation and administration.
Moreover, further studies should further investigate OSIT safety,
efficacy and costs [17,24,25].

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Copyright: 2015 Snchez Salguero CA. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits
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Citation: Snchez Salguero CA (2015) Oral Desensitization in Nursling with Cows Milk Allergy. Peertechz J Pediatr Ther 1(1): 005-008.

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